2.0 Analysis 2.1 Load Stacked and Secured on Deck The skipper/owner of the STPHANEPII had a permit for 250 traps and, given the permissible load on board, he had to make at least three trips, carrying 83 traps per trip. As he was setting his traps in groups of 8, he could have made two trips with 80 traps and another with 88, taking weather conditions into account. It was determined that the STPHANEPII was carrying 96 lobster traps at the time of the accident. To improve the stability characteristics of the vessel, the skipper/owner could have stowed two groups of 8 traps in the hold. This method entailed certain difficulties, but it would have improved greatly the vessel's stability. The fact that the traps that were stacked to a height of six feet were secured to the deck contributed to the capsizing. Had they not been secured, several of the traps probably would have fallen overboard when the vessel listed, thereby allowing her to right herself. Furthermore, stowing the traps one on top of the other raised the centre of gravity, thereby contributing to the capsizing. Other vessels in the area reported losing traps overboard the day of the occurrence, but they did not capsize. Many skipper/owners of small fishing vessels have never been alerted to the dangers that some loads may present. 2.2 Decision to Tow the Wreck When he called the MCTS Centre at Rivire-au-Renard after rescuing the survivor, the skipper of one of the first vessels to arrive on the scene asked if he should tow the capsized vessel to the wharf. The MCTS Centre told him that the MRSC wanted him to try to get closer to see if he could hear any sounds possibly coming from persons trapped inside the wheel-house, and, if possible, to try to tow the vessel. Apparently, the vessel was to be towed in order to bring her back into shallower water in case she sank as well as to facilitate inspection of the inside bydivers. It seems that the lashings used to secure the traps broke during the towing operation. The lobster traps then sank, and the skipper's body may have been dragged to the bottom at that time. His body was later found tangled in the cables among the traps. 2.3 Chances of Survival On leaving the harbour, the fisherman's helper and the guest were sitting forward of the wheel-house. Shortly thereafter, the skipper asked his helper to go check the traps at the stern because the vessel was beginning to roll heavily. The fisherman's helper and the guest proceeded to the stern. The guest stood in the doorway of the wheel-house while the helper checked the traps. The skipper then saw a large wave coming and warned his companions that it was a dangerous one. He began to turn the vessel to face into it, but he did not have time to complete the manoeuvre. When the vessel capsized, the skipper was in the wheel-house, the helper was on deck leaning against the traps and the guest held on to the doorway. None of them was wearing a personal flotation device (PFD). After the vessel capsized, even if the occupants were still conscious, they had little chance of returning to the surface because of the water temperature (2C) and disorientation. When the body rotates under water and gravity references are lost, disorientation is inevitable, and it is difficult for the occupants of a capsized vessel to escape. Darkness would have increased disorientation. In-rushing water has four major effects, all of which can lead to drowning. The first is panic, because the individual is exposed to potential drowning; the second is uncontrolled hyperventilation and reduction of the ability to hold one's breath; the third is being tossed about in a confined space like the wheel-house of the STPHANEPII, which can lead to intense disorientation. The fourth effect, immersion in cold water, exacerbates the first two. If water temperature is below 10C and the survivors are not wearing survival suits, a combination of factors can lead to drowning: panic, hyperventilation, reduction of the ability to hold one's breath, and the possibility of cardiac arrest or arrhythmia. According to a study done by the North Atlantic Treaty Organization (NATO) Advisory Group for Aerospace Research and Development (AGARD) entitled The Human Factors Relating to Escape and Survival from Helicopters Ditching in Water, only those who have experienced disorientation in an underwater escape simulator have a good chance of understanding the problem and solving it. Even experienced professional divers are surprised by the profound sense of disorientation that they suffer the first time they try the simulator. The study revealed that, in spite of their lengthy experience, 16 out of 24 divers testing escape hatch illumination became seriously disoriented and needed assistance.[4] 3.0 Conclusions 3.1 Findings The sea was rough because of the strong winds of the preceding days. The centre of gravity was raised because the load was stacked and secured on deck. The fish hold was empty, and that worsened the stability characteristics of the vessel. No one on board was wearing either a lifejacket or a personal flotation device (PFD). It is very likely that disorientation played a role in the loss of the two lives on board the STPHANEPII. No one on board had any formal knowledge of vessel stability. With the fish hold loaded to 90% capacity, the static and dynamic stability characteristics of the STPHANEPII would be higher than the normally required values. The STPHANEPII capsized because of the low margin of static and dynamic stability caused by stacking the traps on deck. 3.2 Causes The small fishing vessel STPHANEPII capsized shortly after leaving the harbour of Gascons because of the adverse effect that the load of lobster traps stacked and secured on deck had on the stability of the vessel. The small margin of static and dynamic stability was lost when the vessel listed after being struck by a wave larger than the rest. 4.0 Safety Action 4.1 Safety Concern 4.1.1 Small Fishing Vessel Loading Practices During its investigation of occurrences involving fishing vessels, the TSB has observed that many crews on fishing vessels do not fully appreciate that some of their day-to-day operating procedures may be creating unsafe conditions. Therefore, in its report on the investigation into the 1995 sinking of the PACIFIC BANDIT off Barkley Sound in British Columbia (TSBReportNo.M95W0005), the Board recommended that: The Department of Transport, in conjunction with other government departments, agencies, and organizations, immediately undertake a national safety promotion program for operators and crews of small fishing vessels to increase their awareness of the effects of unsafe operating practices on vessel stability; and The Department of Transport conduct a study to identify the extent of unsafe loading and operating practices used by fishermen on small fishing vessels, with a view to developing guidelines for the safe operation of small fishing vessels. In reply to these recommendations, Transport Canada (TC) indicated that it believes that the existing guidelines on the safe operation of small fishing vessels are adequate. TC further advised that in 1994, the Canadian Coast Guard (CCG) had sponsored an independent evaluation study of those Non-Regulatory Marine Occurrence Prevention Programs (NRMOPP) aimed at recreational vessels and commercial fishing vessels of less than 15 gross registered tons (grt). PhaseI[5] of the study, completed in 1995, recognized the relationship between education, awareness, positive safety attitudes and changed behaviours. TC now intends to proceed with PhaseII of this study in order to determine and substantiate the relevance and effectiveness of existing safety promotion programs and their delivery. The Board believes, however, that its investigations have already shown that the safety message of some CCG programs is not getting through to those who are actually operating and crewing small vessels. As such, while the proposed PhaseII of the study could better identify the weak areas and give rise to recommended corrective measures over the long term, the Board is concerned that, without specific action in the interim, unsafe loading and operating practices, such as those used on the STPHANEPII, will continue to put fishing vessels and their crews at risk.